317005468-4-6-2023-25-AS-KHOS-CQSNAK-20230411101741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005468
Report Date: 04/06/2023
Date Signed: 04/06/2023 10:40:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2022 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20221201161953

FACILITY NAME:	BROOKDALE AUBURN		FACILITY NUMBER:	317005468
ADMINISTRATOR:	MORGAN WHINERY		FACILITY TYPE:	740
ADDRESS:	11550 EDUCATION ST		TELEPHONE:	(530) 888-8847
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	110	CENSUS: 63	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Malissa Acuna, Administrator		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Staff are not following a licensed physician's orders
Staff did not comply with an infection control practice
Responsible party was not notified that resident was sick
Staff refused to clean residents' room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to deliver complaint findings regarding the above allegations. LPA met with Administrator Malissa Acuna during today's inspect. LPA ensured she applied hand sanitizer before entering the facility.

LPA investigated allegation, "Staff are not following a licensed physician's orders". During the investigation LPA reviewed documents, and conducted interviews with staff, residents, and relevant parties. R1 was taken to the emergency department and tested positive for covid on November 30, 2022. R1 returned home the same day and isolated in their room. LPA reviewed “After visit summary” documentation from the hospital in which it states to “follow these recommendations as told by your health care provider”.

Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 25-AS-20221201161953

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE AUBURN	FACILITY NUMBER: 317005468
	VISIT DATE: 04/06/2023

NARRATIVE

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Documentation then states the foods/drinks R1 should avoid and it states for R1 to eat bland, easy to digest foods like rice, bananas, applesauce, lean meats, toast and crackers. Relevant party indicates that the after visit summary was provided to the facility, however the bland foods were not provided to R1. Relevant party indicates that they had to follow up with facility for them to finally serve R1 bland foods like rice. LPA interviewed staff members in which they stated R1 refused a bland diet and so other foods were provided to R1. LPA reviewed facility documentation, in which they indicate on R1’s progress notes on 12/2/22 that R1 is requesting regular food to be brought to her because her health issues had resolved and R1 is feeling better. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated the allegation, "Staff did not comply with an infection control practice". LPA reviewed what facility reported to CCL in November 2022. Reports indicate facility had 3 covid positive clients between the time period of November 20^th through November 30^th 2022. 2 of 3 COVID positive clients were couple R1 and R2 who were sharing a room. All three clients were isolated in their rooms. LPA interviewed relevant party in which she stated R1 and R2 were never tested for COVID even though they were showing symptoms. Relevant party stated during the time period of R1 and R2 having symptoms and before they were tested, they were out in the facility around other residents. Facility had a different administrator during this incident time period and new administrator does not have documentation of communication with department of public health. Interviews with staff indicate that R1 and R2 were isolated upon testing positive for covid. LPA finds allegation to be UNSUBSTANTIATED.

LPA investigated the allegation, "Responsible party was not notified that resident was sick."Relevant party informed LPA that facility failed to inform residents responsible party that residents (R1, R2) had a change of condition. Relevant party indicated that residents had covid like symptoms and facility staff never reported this to responsible party.

Continuation on 9099-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20221201161953

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE AUBURN	FACILITY NUMBER: 317005468
	VISIT DATE: 04/06/2023

NARRATIVE

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Relevant party indicated that responsible party found out from R1 about their covid like symptoms. Responsible party then took R1 to the emergency department and R1 tested positive for COVID. Relevant party indicated that R1 informed staff they were not feeling well and having symptoms however staff did not report this to responsible party. LPA interviewed R1 and they stated they could not remember who they reported covid symptoms too, and was unsure when they reported the covid symptoms to staff. LPA interviewed facility, in which they stated R1 and R2 are not on any care services and do not require help from staff. Staff indicated that R1 usually reports all changes of condition or any pertinent information to their responsible party and then the responsible party reports the issue with the facility. Staff are not aware of a time that they did not report changes with responsible party. Due to the conflicting information, LPA finds allegation to be unsubstantiated.
LPA investigated allegation, "Staff refused to clean residents' room". During the investigation LPA interviewed staff, residents, and relevant party. Relevant party reported to LPA that facility refused to clean R1 and R2’s room when residents had tested positive for COVID and prior when they had symptoms. Relevant party stated that R1 had required extra cleaning due to an accident that occurred, and staff refused to help R1 clean. In addition, when R1 and R2 had confirmed covid cases housekeeping did not clean R1 and R2’s room. LPA interviewed maintenance Director assistant (MDA) which helps oversee housekeeping. MDA stated they do not remember that incident specifically however housekeeping cleans residents’ room even when residents are isolating due to COVID-19. MDA stated the housekeeping wear more PPE when entering a positive covid case room, and they continue to complete their weekly housekeeping duties. MDA stated that someone from housekeeping is at the facility from 8-5 and if a resident needs more cleaning due to an accident, housekeeping will help clean up. MDA stated he is unaware of a time housekeeping refused to help R1 and R2. LPA interviewed care staff in which they stated they do not recall a time that they refused to help R1 or R2 with cleaning up. Due to conflicting information LPA finds allegation to be unsubstantiated.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
An exit interview was conducted. A copy of the report was provided to facility administrator.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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